Is it ethical, or even legally acceptable, for doctors to approve one last dance by a reality TV show contestant if it could lead to permanent damage to his back? These are the kinds of legal questions University of Virginia law professor Dr. Gil Siegal tackled recently when he led the design of a code of ethics for Israeli reality TV shows such as “Dancing with the Stars” and “Big Brother.”

Siegal –­ who holds an M.D. from Tel Aviv University, in addition to law degrees from there and U.Va. – began looking into reality show ethics after public attention was drawn to the Israeli version of “Big Brother.” A psychiatrist working on behalf of “Big Brother” ­– which is currently shooting its fifth season in Israel – was accused of unethical behavior in its last season, most notably using information about the contestants to manipulate them and prescribing them medication not for their benefit, but to make the show more dramatic or to keep them from quitting. The allegations were later refuted, Siegal said, but the need for a code became apparent.

The broadcasting company, Keshet, subsequently hired Siegal to design a code of ethics that has been put in place for a number of its programs, including versions of “The Voice,” “MasterChef” and “Big Brother.”

Siegal, who is also director of the Center for Health Law and Bioethics at Kiryat Ono College in Israel and a member of the National Bioethics Committee, said the reality TV code of ethics he designed is believed to be the first of its kind.

“Reviewing the literature was really easy because there’s nothing out there,” he said at a recent lunchtime talk at U.Va.’s Law School. “We realized that we were doing something really new.”

The allegations against “Big Brother” led to a lawsuit by several participants in 2012, which was reportedly settled out of court for $600,000 earlier this month, Siegal said.

During the lawsuit, however, the CEO of Keshet decided to hire Siegal to serve as the company’s chief ethical medical officer and to design a code of ethics that would serve as a model for all of Israel’s reality TV programs.

“Even though it’s beyond the realm of conventional scholarship, I accepted the challenge,” Siegal said. “What’s the term in country music? Get some mud on my boots? I don’t mind getting some down-to-earth challenging cases.”

Siegal chaired a committee of three other lawyers, including one with a doctorate in mass communication, to create the ethics guidelines. They met with a number of experts, reality show producers, contestants and government regulators who oversee Israeli broadcasting for input. And they began to search for similar models of evaluating ethics – but without finding one that perfectly fit the world of reality TV.

For example, Siegal said, the code of ethics pertaining to human subject medical research could be somewhat similar, as both human test subjects and reality TV contestants volunteer to subject themselves to a process that might not be pleasant or even harmful (physically such as in “Risk Factor” shows, and mentally, such as the three-month isolation of “Big Brother”). Yet a key difference is that human test subjects often volunteer for altruistic purposes, whereas reality TV participants are generally signing up for exposure or the chance to win a prize.

As they designed their reality TV code, Siegal and the committee took elements of various frameworks, including human subject research, medical informed consent, employment law and more.

Ultimately, he said, the core principal of their ethical model ended up being perhaps most similar to competitive sports.

In sports, he pointed out, doctors generally will bench an athlete who suffers a significant injury, such as a concussion, but still might allow an athlete to continue playing in the event of a less-serious injury, particularly in the case of an important game. In such scenarios, the medical team must confront an obvious conflict of interest between the wellbeing of the participant and the interest of the team or owner.

Under the reality TV code they designed, the programs’ producers must safeguard the wellbeing of participants in order to ensure their physical and mental health will not be significantly or irreversibly harmed.

“Think about a guy on a show about dancing, suffering from a burst disc,” Siegal said. “If he’s going to do this [dance], he’s going to have to go into surgery. But it’s the finals. Should he or shouldn’t he [be allowed]?

“Or think about a singing competition. Say a contestant loses her voice and … if she sings, she has a massive hematoma on her vocal chords and she can’t sing for several months or would require surgery to resume her career. These are things that could really create significant damage.”

A key underlying assumption of their reality TV guidelines is that competent adults possess physical and mental mechanisms to withstand pressure and challenges, he said.

The guidelines also require producers to take into consideration participants’ disabilities and their physical health and mental condition without discriminating against them.

“If a producer thinks, ‘I don’t want to get in trouble, I’m only going to get people who are perfectly healthy, no issue.’ Then what you create is a bias against people with disabilities,” he said. “If he’s deaf, if he’s blind, if he’s epileptic, can he or can he not participate in the show? Our view is that discrimination against these participants should not be accepted … Accommodations should be made for those who want to participate, under the condition that it does not create significant danger to those individuals.”

Siegal’s team provides a “toolkit” that requires reality TV show producers to answer questions about their show’s process, from inception to post-production. Siegal, as Keshet’s chief ethical medical officer, reviews the producers’ responses.

Under the guidelines, producers must respect participants’ medical confidentiality and must train their staff to protect that confidentiality. It also requires professional autonomy of the show’s supervising medical team to lessen the conflict of interests.

When the code of ethics for reality TV began rolling out, Siegal said, it was met with skepticism by producers, TV critics and regulators. After five months, however, they are seeing an excellent level of compliance, he said.

“Most have bought into it,” he said. “They’re happy that there’s a well-structured procedure in place to promote the well-being of participants while maintaining the creativity and interest in reality TV.”

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